Abstract
The treatment of atrophic fracture nonunion continues to represent a
therapeutic challenge. Large segmental osteopenia is often seen in patients who
received uniplanar or hybrid external fixators as the definitive method of
fixation for high-energy fractures, and this adds more difficulties to the
treatment of fracture nonunion. This retrospective study was designed to assess
the outcome of locking compression plating with autologous bone grafting in
patients with long-bone atrophic nonunion following external fixation.
From January 2004 to December 2009, a series of consecutive patients
with atrophic nonunion of the long bone following external fixation were
treated with this method in our institution. The clinical outcomes and
complications of these patients were retrospectively analyzed. Twenty-seven
patients with 28 fracture nonunions were involved in this study. Mean follow-up
was 14.2±3.4 months. Bony union was achieved in all 27 patients within a
mean 18.6±4.8 weeks after revision surgery. Two patients developed
superficial wound infections. No deep infections were found, and no implant
failure was seen. Three patients reported minor pain in the donor site of the
bone graft, and no other donor site complications were found.
Revision osteosynthesis of long-bone atrophic nonunion following
external fixation by locking compression plating with autologous iliac crest
bone grafting represents a safe and efficacious modality for the treatment of
these challenging conditions.
External fixation is often used in high-energy polytrauma patients who
may have open wounds, massive soft tissue injury, bony comminution, or bone
loss unsuitable for acute internal fixation. Such patients are more likely to
develop atrophic nonunion due to severe devascularization of the fractured bone
and poor quality of soft tissue bed compared to those patients with low-energy
fractures. Furthermore, large segmental osteopenia is often seen in patients
who received uniplanar or hybrid external fixators as the definitive method of
fixation because of the stress shielding effect of the fixator and disuse of
the limbs. These patients become a therapeutic challenge if they develop
fracture nonunion due to the poor quality of the bone and surrounding soft
tissue.
Locking plates have been used successfully in the treatment of
osteoporotic fractures in which bone quality was poor.1,2 The
locking compression plate provides compression while maintaining fixation of
poor-quality bone. It also requires minimal stripping of soft tissue
surrounding the fracture site since it was placed in the periosteum. The
locking compression plate has recently been proven successful in treatment of
atrophic nonunions.3,4 To advocate the use of this technique,
further evidence is needed.
This retrospective study was designed to assess the outcome of locking
compression plating with autologous bone grafting in patients with long-bone
atrophic nonunions following external fixation.
Materials and Methods
A series of consecutive patients treated with locking compression
plating and autologous bone grafting for long-bone fracture nonunion following
external fixation in our orthopedic department between January 2004 and
December 2009 were retrospectively analyzed. Patients were included if they
received external fixation as the definitive treatment for fracture and then
developed nonunion that was treated with locking compression plating and
autologous bone grafting. Exclusion criteria for this study were pathologic
fracture, severe systemic illness (active cancer, chemotherapy,
insulin-dependent diabetes, renal failure, hemophilia, or a medical
contraindication for surgery), open growth plates, age older than 65 years,
bone defect >5 cm, and infected nonunion. The presence of infection was
excluded by preoperative analysis of systemic infection parameters (white blood
count, sedimentation rate, C-reactive protein) and by culture and
histopathologic analysis of tissue samples from the resected nonunion. All
patients were treated for nonunion by the same team of surgeons (S.S., Y.Z.,
L.Z., J.L., D.F., B.M.), who followed similar operative and postoperative
procedures. This study was approved by the hospital ethics committee, and all
patients gave their informed consent before inclusion in the study.
Surgical Technique
The external fixators were removed, pin tracks scraped, and limbs
placed in braces for 7 to 14 days. Oral antibiotics were administered for 3 to
5 days if a pin-track infection was found, and surgery was delayed until the
pin-track infection was resolved. The least amount of soft tissue stripping
necessary was used to expose the nonunion sites. All fibrous and scar tissue
was removed from around the nonunion site, including the entire pseudocapsule.
The fibrous covering over the intramedullary canal on both sides was removed
using curettes and drills until a well-vascularized bone bed was observed. The
autologous bone graft taken from iliac crest was placed in the fracture site.
Osteothesis was performed with a locking compression plate (Weigal Orthopaedic
Device Co Ltd, Yantai, Shandong, China) after anatomical reduction was
achieved. Compression in the fracture site was always performed when possible
(Figure).
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| Figure: Double bone
fractures in the left forearm of a 41-year-old man were treated with external
fixation (A). After 6 months’ fixation, atrophic nonunions in the ulna and
radius were identified (B). Revision surgery was performed with locking
compression plating and autologous bone grafting (C). Bony union was achieved
18 weeks after revision surgery (D). Bone remodeling can be seen 28 weeks after
revision surgery (E). |
No external immobilization was necessary. On postoperative day 1,
gentle activity was initiated. Aggressive range of motion exercises and partial
weight bearing was started as soon as tolerated by the patient. Full weight
bearing was permitted only after clinicoradiological evidence of union. Union
was defined as the absence of pain and motion at the fracture site and bridging
bone across 3 cortices on plain radiographs. Patients were followed up at
monthly intervals for the first 6 months postoperatively and then every 2
months for up to 1 year to assess progress of union and possible
complications.
Results
Twenty-seven patients with 28 fracture nonunions were enrolled in this
study (Table). Mean time between primary fixation and revision surgery was
9.3±2.8 months. Mean follow-up after revision surgery was
14.2±3.4 months.
Bony union was achieved in all 28 nonunions (27 patients)
18.6±4.8 weeks after revision surgery (Figure). Two tibial diaphyseal
nonunions showed minimal callus on radiographs 24 weeks postoperatively and
were further treated with low-intensity pulsed ultrasound. Bony union was
achieved at 32 and 36 weeks, respectively. Both of the patients were active
smokers.
All patients reported significant improvement in pain and function of
limbs. Two patients developed superficial wound infections that resolved with
debridement and oral antibiotics. No deep infection was found. Three patients
reported minor donor site pain. No other complications (such as neurovascular
injury, fracture including avulsion of the anterior superior iliac spine,
infection, hematoma, herniation of abdominal contents, and gait disturbance)
were found.
Discussion
Approximately 5% to 10% of fractures develop nonunions and/or delayed
unions, which result in a large burden for patients and society.5
The management of fracture nonunion remains challenging to most surgeons. For
those atrophic nonunions with bone defection and poor bone quality, the
treatment becomes more difficult. We treated 27 patients with 28 long-bone
atrophic nonunions with locking compression plating and autologous bone
grafting, and achieved good results with 100% union rate and functional
improvement.
The cause of fracture nonunion is usually unknown. The known reasons
of impaired unions include complications with operative and nonoperative
interventions, inadequate mobilization of the fracture, distraction of fracture
fragments by fixation devices or traction, repeated manipulations or excessive
early motion of a fracture, excessive periosteal stripping, and damage to other
soft tissues during operative exposure. Other risks for impaired fracture
healing include smoking, diabetes, and the location of the injury.6
In our series of patients, devascularization of the fractured bone and poor
quality of the soft tissue due to high-energy trauma could contribute to
fracture nonunions. Improper use of the external fixator intra- and
postoperatively may also contribute to fracture nonunions.
Surgical techniques for revision of fracture nonunions include
intramedullary nailing and plating and external fixating. Conflicting results
have been reported for both techniques. The locking compression plate was
designed to overcome the pitfalls of conventional plates, particularly when
dealing with difficult problems such as comminuted, metaphyseal, and
osteoporotic fractures. Its advantages have been demonstrated by several
studies.2,7,8 It has also been successfully used in the treatment of
fracture nonunions.3,4 In this study, the locking compression plate
provided enhanced stability for osteopenic bone, and no implant failure or
pullout was found postoperatively. Additionally, the locking compression plate
was placed on the periosteum, which did not demand wide stripping of soft
tissue surrounding the nonunion sites. Therefore, the vascular supply to the
nonunion sites was maximally preserved. Twenty-eight nonunions in this study
achieved bone in a mean time of 18.264.7 weeks, with a union rate of
100%.
Strategies to bridge bone defects include autologous or allogeneic
bone grafts and bone transfer and bone substitute combined with osteogenic
stimulators. For short-bone defects, autologous iliac crest bone graft or bone
substitute combined with osteogenic stimulators (eg, bone morphogenetic
proteins) are the most commonly used techniques. Despite the possibility of
donor site complications, autologous iliac crest bone graft provides the
quickest and most reliable type of bone graft, and it is held by some authors
to be the gold standard for the treatment of short-bone defects.9,10
It also has an economic advantage compared to bone substitute combined with
osteogenic stimulators. In our series of patients, only 3 patients reported
minor donor site pain. There were no other complications such as neurovascular
injury, fracture including avulsion of the anterior superior iliac spine,
infection, hematoma, herniation of abdominal contents, and gait disturbance.
Careful intraoperative manipulation and harvest of the minimal amount of bone
necessary helped to reduce the rate of donor site complications.
Despite excellent and encouraging early results, our study has some
limitations. The series includes a relatively small number of patients, and the
method was not compared with another method prospectively to investigate if the
outcomes are superior.
Conclusion
Locking compression plating with autologous bone grafting for the
treatment of long-bone atrophic nonunion following external fixation provides a
high union rate and enables initiation of early active unlimited motion. In
this study, excellent results were achieved without major complications at
short- and mid-term follow-up.
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Authors
Drs Sun, Zhang, Zheng, Li, Fan, and Ma are from the Department of
Orthopedic Surgery, Tangdu Hospital, the Fourth Military Medical University,
Xi’an, Shaanxi Province, PR China.
Drs Sun, Zhang, Zheng, Li, Fan, and Ma have no relevant financial
relationships to disclose.
Si-guo Sun, MD, and Yong Zhang, MD, contributed equally to this
study.
Correspondence should be addressed to: Bao-an Ma, MD, Department of
Orthopedic Surgery, Tangdu Hospital, the Fourth Military Medical University,
Xi’an, Shaanxi Province, 710038, PR China (mabaoanfmmu@126.com).
doi: 10.3928/01477447-20110317-12